Article by David Reece, BSN, RN, CCDS, Consulting Director, Outpatient CDI Solutions, MedPartners University
The debate around what constitutes Outpatient Clinical Documentation Improvement (CDI) has been going on for some time now. I think in order to define Outpatient CDI, it’s helpful to first define the core functions of Outpatient CDI. Through the process of medical record review, a Clinical Documentation Specialist (CDS) looks for documentation gaps in order to properly and accurately capture the patient’s acuity, severity of illness, and utilization of services. CDI professionals serve as the bridge between Health Information Management and clinical staff.
By conducting reviews, a CDS also gathers trending data to track problematic issues, educate providers, and participates in process improvement activities with other departments. These CDI core functions sound a lot like an Inpatient CDI program and that’s because they are. It’s not that the role has changed;it’s the setting and the focus of reviews that are different. There are multiple settings in which an Outpatient CDI program can flourish and make positive impacts. While each setting is unique, the areas of opportunities and focus often overlap. Opportunities within the settings can include risk adjustment, Evaluation and Management (E&M) levels, clinical validation, charge capture, quality metrics, electronic health record compliance, denials management, and medical necessity.
In the following paragraphs, I will break down the settings into two main groups along with the areas of focus or opportunities for each. The first setting is in the Emergency Department where CDI has a multitude of opportunities.As an adjunct to the Inpatient CDI team, a CDS can start reviewing cases that are being admitted and assisting providers in properly documenting POA status and those all too often challenging diagnoses that are difficult to clarify once the patient leaves the ED, such as respiratory failure and pressure ulcer stages.
A CDS can assist in the accurate capture of infusion times;improve documentation supporting observation or inpatient criteria, E&M levels, and medical necessity for procedures and tests; charge capture validation; creation of an accurate problem list; and capture of crucial data elements associated with quality of care measures. For observation services, CDS should strive to work collaboratively with the Case Management and Utilization Review teams and not viewed as a replacement of their services.
Ambulatory clinics are the second setting which is much broader and covers areas such as primary care services or physician clinics, infusion services, diagnostics, ambulatory surgery, and wound care clinics. In primary care clinics, a CDS may review records prospectively, concurrently, or retrospectively to ensure accurate and complete documentation of diagnoses and clinical indicators that impact the HCC assignment and the associated risk adjustment factor (RAF) scores.
Through retrospective reviews, CDI efforts can positively affect the specificity of the patient’s condition(s) using ICD-10-CM verbiage and the documentation of complete and detailed medical decision-makingto support E&M levels. As a CDS covering an infusion clinic, areas of opportunity would include the documentation of an order for Peer reviewed/proofed vb 4/18/19 Final ready for Marketing-4/19/19 JS approval services, the type of infusion, the infusion route and site, stop and start times, as well as nursing and provider documentation that is consistent for the accurate billing of services.
Reviewing medical records in an ambulatory surgical center helps to ensure that medical necessity for outpatient procedures is clearly documented and meets relevant National Coverage Determination and Local Coverage Determination requirements for the procedure performed.
For accurate coding and reporting in a wound care clinic, the provider must document the diagnosis of a wound and its location, including laterality, wound type (e.g., pressure ulcer, chronic ulcer, non-healing surgical wound, etc.) and the cause of the wound, when applicable.For a diagnostic clinic, a CDS has the opportunity to clarify documentation requirements for diagnostic testing versus screening services.While the core functions of CDI have not changed, the settings do offer challenges not typically seen on the inpatient side. Time and volume are two major key factors for the Outpatient CDI team. The amount of time a CDS has to review a record is much shorter, patient visits are brief –sometimes only lasting a few minutes, and opportunities to interact with a provider who has a heavy schedule may be very challenging.
The volume of patients a provider can see in the ED or ambulatory clinic is typically much higher than that of an inpatient provider. Due to such high volumes, this often meansthe scope of reviews may need to be limited to certain patient populations, payers, disease registries, or areas of high impact related to denials. As a leader in CDI staffing, training, auditing, workflow assessments, and program implementation, MedPartners has the experience and solutions to ensure a successful journey into Outpatient CDI regardless of the setting, focus, or how Outpatient CDI is defined.